ENVIRONMENTAL ROUNDS WORKSHEET FOR INFECTION PREVENTION
AREA INSPECTED:DATE:INSPECTOR:

Use separate sheet for each department or patient care unit. Check as follows:
C = Compliant; NC = Not compliant; CAC = Corrective action completed; FU = Follow-up required; NA = Not applicable

Criteria

CNC

Finding or CommentCAC

FUNA

Patient Rooms:
Floors & walls clean
Walls are free of breaks and penetrations
Bathroom clean
Sink clean
Furniture clean and in good condition
Windows and windowsills clean
Irrigation & sterile solutions labeled as per policyPeripheral IVs, CVC, arterial lines labeled as per policy
Foley catheters hanging appropriately
IV pumps, Feeding pumps, etc. clean (while in use)
Gloves, PPE, available as per policy
Barriers used appropriately
Bed pans & urinals labeled as appropriate
Cubicle curtains clean and free of tears, etc.
Isolation Rooms:
Appropriate sign(s) posted
Isolation equipment available
PPE available
Door closed as appropriate
Negative pressure being supplied as required
Air exchanges being supplied as required
Patient instructed on isolation requirements
Patient with proper attire when being transported
Treatment & Examination Rooms:
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CriteriaCNC

Finding or CommentCACFUNAFloors & walls clean
Countertops clean
Exam table clean
Furniture clean and in good condition
Utility & Storage Rooms:
Adequate separation of clean & soiled
Floors and walls clean
No supplies stored on the floor
Supplies stored 6” from floor
Supplies stored 18” from ceiling
No supplies stored under sinks
No supplies stored in bathrooms, soiled utility rooms
Supplies stored away from windows, vents
Shelving/drawers/cabinets clean
Patient supplies within expiration dates
Sterilized trays free of dust, unopened, tears
Event-related sterile items labeled appropriately
Soiled Utility Rooms:
Floors and walls clean
Free of patient supplies and sterilized trays
Bedpan flusher clean
Soiled linen is bagged & placed in transport truck
Hallways:
Floors and walls clean
Free of obstruction and equipment
Equipment & Non-Critical Items:
Equipment in patient use clean
Equipment stored is clean
Equipment handled as per policy
Linen:
Clean linen distributed to units on clean, covered carts
Separation of clean & soiled linen
Page 2Criteria

CNC

Finding or CommentCACFUNA

Clean linen stored in required area, on shelves or carts
Soiled linen not placed on floor, furniture, windowsills, etc.
Soiled linen collected as per policy
Soiled linen contained in bags, not overfilled
Linen hampers & carts covered
Linen hampers & carts clean & in good condition
Offices, Work Stations & Reception Areas:
Carpeting clean
Desks clean and free from unnecessary clutter & food items
Office equipment clean & free from clutter
Floors free of clutter & trash
Food only in designated areas
Meeting Rooms:
Carpeting clean
Empty cups & food items placed in trash
Furniture clean & in good condition
Waiting Areas & Staff Lounges:
Carpeting clean
Furniture clean & in good condition
Empty cups & food items placed in trash
Waste Management:
Waste containers not overfilled
Waste containers clean, operational, & in good condition
Waste containers covered as required
Containers located appropriately
Appropriate number of containers available
Containers labeled as required
Red bag available in each regulated medical waste container
Regulated medical waste discarded appropriately
Items in regulated medical waste containers are appropriate
Sharps containers available
Sharps containers not overfilled
Sharps containers secured appropriately
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CriteriaCNC

Finding or CommentCACFUNA

No capped syringes in containers
Sharps appropriately discarded
Other Housekeeping Issues:
Handwashing sink is available
Hand towels are available
Hand towel dispenser available/operable
Handwashing solution is available
Soap is appropriate for area/unit
Handwashing solution dispenser available/operable
Waterless soap is available to the staff
No bar soap
Area free of roaches, flies, mice & other vermin
Blood spill kits available
Tubs/showers are clean
Vent grills clean
High-level dusting performed
Porter’s closet cleanHousekeeping staff aware of cleaning solution admixing policy
Pantry:Floors & walls clean
No expired juice/milk, etc.
Ice machine clean
Microwave clean
Refrigerators:
Daily checklist completed for temperatures
Correct temp observed: Food & drink, 36-45 F
Correct temp observed: Medications, 36-46 F
Correct temp observed: Specimens, 36-46 F
Correct temp observed: Blood, 34-43 F
Correct temp observed: Freezers, 32 F
Only medications in medication refrigerator
Only food in food refrigerator
Only specimens in specimen refrigerator
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CriteriaCNC

Finding or CommentCACFUNA

Patient food & staff food not mixed
Refrigerator clean
Items labeled as per policy
Medications:No outdated IV solutions or medications
Open vials dated and timed as per policy
Medication carts clean and organized
Elevators:
Floors & walls clean
Designated elevators used appropriately
Miscellaneous:Handwashing observed when appropriate
Ceiling tiles are clean and in good condition
Ceiling is free of holes and penetrations
Disaster, evacuation, fire, infection control, & MSDS documents
available
Storage closets and shelves
Sink clean
Area free of water leaks or spills
Specimens being bagged, handled, labeled as per policy
Safety devices available
Safety devices used appropriately
Grounds:
Clean & free of trash
Building walls free of penetrations
Disinfection/Sterilization:
Appropriate solutions available for soaking
Appropriate containers available
Containers clean, covered, labeled as required
Instruments/devices being processed correctlyQA program for gluteraldehyde
Sterilizers clean
Page 5

CriteriaCNCFinding or CommentCAC

FUNA

Sterilizers functioning properly
Sterilizer preventive maintenance available
Sterilization parameters maintained
Chemical/Biological monitors used as per policy
Sterilization records/documentation complete
CORRECTIVE ACTIONS:REPORT SENT TO:(https://www.google.co.jp/search?source=hp&ei=nyiaW9PENIm98QXabfACw&q=ENVIRONMENTAL+ROUNDS+WORKSHEET+FOR+INFECTION+PREVENTION%E3%80%80APIC&oq=ENVIRONMENTAL+ROUNDS+WORKSHEET+FOR+INFECTION+PREVENTION%E3%80%80APIC&gs_l=psy-ab.3...144.4102.0.4705.7.6.0.0.0.0.147.605.3j3.6.0....0...1.1j4.64.psyab..1.2.176.0..0i203k1j0i30k1.0.QwRlHlXfpIA)

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